Basic Information
| Provider Information | |||||||||
| NPI: | 1962656082 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FRESNO COMMUNITY HOSPITAL AND MEDICAL CENTER | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | COMMUNITY BEHAVORIAL HEALTH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7171 N CEDAR AVE | ||||||||
| Address2: | |||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937203311 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5594591672 | ||||||||
| FaxNumber: | 5594591058 | ||||||||
| Practice Location | |||||||||
| Address1: | 7171 N CEDAR AVE | ||||||||
| Address2: | |||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937203311 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5594591672 | ||||||||
| FaxNumber: | 5594591058 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/17/2008 | ||||||||
| LastUpdateDate: | 05/30/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CASTRO | ||||||||
| AuthorizedOfficialFirstName: | CRAIG | ||||||||
| AuthorizedOfficialMiddleName: | STANLEY | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5593244884 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | COMMUNITY REGIONAL MEDICAL CENTER | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/30/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273R00000X | 040000096 | CA | Y | Hospital Units | Psychiatric Unit |
ID Information
| ID | Type | State | Issuer | Description | HSM00060F | 05 | CA | MEDICAID |